How should paediatricians assess Gillick competence?

Abstract

Competence is an essential legal requirement for valid consent to medical treatment. Children under 16 may be considered 'Gillick competent' to make treatment decisions, but may need to demonstrate this. Applied tests for competence are wide-ranging and context dependent. Competence is related to cognitive ability and experience and may be enhanced by education, encouragement etc.; there is a general duty for professionals to enhance the competence of children in their care. The need to assess a child's competence may occur when s/he wishes to make a controversial decision whose wisdom others dispute. Potential assessors should have the necessary practical skills and an understanding of the child in their social and medical context. Assessments should be developmentally appropriate, explore systemic influences, and consider the child's emotional state, cognitive development and ability to balance risks and benefits. The involvement of a psychologist or other independent third party should be considered in cases that raise serious concerns about competency, or that involve complex decisions or conflict between the various parties. In rare cases courts may be involved.

Clarifying assent in pediatric research

“…The concept of the Gillickcompetent child refers to a child below the age of 16 who is considered mature enough to be legally allowed to give consent to a clinical procedure. 61 It has been proposed that the concept of Gillick competency can be applied to pediatric research as well. 62 For personalized assent an (inter)active structure of assent is required -the content and the process needs to be adjustable to the individual child and assent should be thought of as an ongoing process instead of a single act.…”

Assessing an Adolescent's Capacity for Autonomous Decision-Making in Clinical Care

“…As summarized in Figure 1, the capacity for autonomous decision-making is not a fixed, predetermined state but is largely dependent on how the adults and professionals in charge address the various aspects of the adolescent's condition, development, and circumstances [3,8]. It is the health care provider's duty to "empower" the adolescent in his decision-making capacity.…”

“…Some countries or states have defined in the law at what age minors can make decisions regarding their health, but in most countries, such age limits are not defined, and it is then necessary for the health care provider and team to assess the young patient's competence. In Great Britain, for instance, as a result of a political intervention after a highly publicized case of request for contraception by a girl aged <16 years, an adolescent who is deemed "Gillick competent" is able to prevent their parents viewing her medical records [3], and this competence is usually assessed by the practitioner.…”

“…Such capacity depends on many factors such as the stage of development, the social and cultural environment, and of the complexity of the clinical situation. Some well-validated and largely if not universally accepted instruments and guidelines are available for the assessment of the adults' capacity who suffer from diseases which hinder their cognitive abilities [5e7]; but even if several authors have developed advice as how to assess autonomous decision-making capacity among minors [2,3,8], no universally applicable approach is yet available.…”

Quantitative valuation placed by children and teenagers on participation in two hypothetical research scenarios

“…Inevitably any determination of competency relies on a value judgement by the clinician,6 with capacity to make decisions depending on individual age, rationality and intelligence 7–9. Children often reach the same treatment decisions as adults, and although age is important, the capacity to make autonomous decisions is dependent on other factors such as education and, above all, experience with medical environments and procedures 10…”